<script src="http://max.jotfor.ms/min/g=jotform?3.0.3734" type="text/javascript"></script>
<script type="text/javascript">
   JotForm.init(function(){
      JotForm.setCalendar("8");
      JotForm.setCalendar("17");
      $('input_9').hint('ex: myname@example.com');
      JotForm.totalCounter({"input_20_1002":{"price":"450"},"input_20_1003":{"price":"550"},"input_20_1004":{"price":"1500"}});
      $('input_23').hint('ex: 23');
   });
</script>
<link href="http://max.jotfor.ms/min/g=formCss?3.0.3734" rel="stylesheet" type="text/css" />
<link type="text/css" rel="stylesheet" href="http://jotform.me/css/styles/pastel.css?3.0.3734" />
<style type="text/css">
    .form-label{
        width:150px !important;
    }
    .form-label-left{
        width:150px !important;
    }
    .form-line{
        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:150px !important;
    }
    .form-all{
        width:650px;
        background:rgb(207, 204, 200) url(http://jotform.me/images/noises/noise.png);
        color:#B83378 !important;
        font-family:'Verdana';
        font-size:13px;
    }
    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{
        color:#B83378;
    }

</style>

<form class="jotform-form" action="http://submit.jotform.me/submit/21987757374471/" method="post" name="form_21987757374471" id="21987757374471" accept-charset="utf-8">
  <input type="hidden" name="formID" value="21987757374471" />
  <div class="form-all">
    <ul class="form-section">
      <li id="cid_1" class="form-input-wide">
        <div class="form-header-group">
          <h2 id="header_1" class="form-header">
            Hotel Reservation Booking
          </h2>
        </div>
      </li>
      <li class="form-line" id="id_4">
        <label class="form-label-left" id="label_4" for="input_4">
          Full Name:<span class="form-required">*</span>
        </label>
        <div id="cid_4" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q4_fullName[first]" id="first_4" />
            <label class="form-sub-label" for="first_4" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q4_fullName[middle]" id="middle_4" />
            <label class="form-sub-label" for="middle_4" id="sublabel_middle"> Middle Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q4_fullName[last]" id="last_4" />
            <label class="form-sub-label" for="last_4" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_18">
        <label class="form-label-left" id="label_18" for="input_18">
          Passport Number:<span class="form-required">*</span>
        </label>
        <div id="cid_18" class="form-input">
          <input type="text" class="form-textbox validate[required]" id="input_18" name="q18_passportNumber" size="20" />
        </div>
      </li>
      <li class="form-line" id="id_6">
        <label class="form-label-left" id="label_6" for="input_6">
          Phone Number<span class="form-required">*</span>
        </label>
        <div id="cid_6" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q6_phoneNumber6[area]" id="input_6_area" size="3">
            -
            <label class="form-sub-label" for="input_6_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="tel" name="q6_phoneNumber6[phone]" id="input_6_phone" size="8">
            <label class="form-sub-label" for="input_6_phone" id="sublabel_phone"> Phone Number </label></span>
        </div>
      </li>
      <li class="form-line" id="id_8">
        <label class="form-label-left" id="label_8" for="input_8">
          Arrival - Date/Time<span class="form-required">*</span>
        </label>
        <div id="cid_8" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_8" name="q8_arrival[month]" type="text" size="2" maxlength="2" value="07" /><span class="date-separate">&nbsp;/</span>
            <label class="form-sub-label" for="month_8" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="day_8" name="q8_arrival[day]" type="text" size="2" maxlength="2" value="18" /><span class="date-separate">&nbsp;/</span>
            <label class="form-sub-label" for="day_8" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_8" name="q8_arrival[year]" type="text" size="4" maxlength="4" value="2012" />
            <label class="form-sub-label" for="year_8" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><div id="at_8">
              at
            </div>
            <label class="form-sub-label" for="at_8"> &nbsp;&nbsp;&nbsp; </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="hour_8" name="q8_arrival[hour]" type="text" size="2" maxlength="2" value="07" /><span class="date-separate">&nbsp;:</span>
            <label class="form-sub-label" for="hour_8" id="sublabel_hour"> Hour </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="min_8" name="q8_arrival[min]" type="text" size="2" maxlength="2" value="29" />
            <label class="form-sub-label" for="min_8" id="sublabel_minutes"> Minutes </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="ampm_8" name="q8_arrival[ampm]">
              <option value="AM"> AM </option>
              <option value="PM"> PM </option>
            </select>
            <label class="form-sub-label" for="ampm_8"> &nbsp;&nbsp;&nbsp; </label></span><span class="form-sub-label-container"><img alt="Pick a Date" id="input_8_pick" src="http://jotform.me/images/calendar.png" align="absmiddle" />
            <label class="form-sub-label" for="input_8_pick"> &nbsp;&nbsp;&nbsp; </label></span>
        </div>
      </li>
      <li class="form-line" id="id_17">
        <label class="form-label-left" id="label_17" for="input_17">
          Departure - Date/Time<span class="form-required">*</span>
        </label>
        <div id="cid_17" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="month_17" name="q17_departure17[month]" type="text" size="2" maxlength="2" value="07" /><span class="date-separate">&nbsp;/</span>
            <label class="form-sub-label" for="month_17" id="sublabel_month"> Month </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="day_17" name="q17_departure17[day]" type="text" size="2" maxlength="2" value="18" /><span class="date-separate">&nbsp;/</span>
            <label class="form-sub-label" for="day_17" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="year_17" name="q17_departure17[year]" type="text" size="4" maxlength="4" value="2012" />
            <label class="form-sub-label" for="year_17" id="sublabel_year"> Year </label></span><span class="form-sub-label-container"><div id="at_17">
              at
            </div>
            <label class="form-sub-label" for="at_17"> &nbsp;&nbsp;&nbsp; </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="hour_17" name="q17_departure17[hour]" type="text" size="2" maxlength="2" value="07" /><span class="date-separate">&nbsp;:</span>
            <label class="form-sub-label" for="hour_17" id="sublabel_hour"> Hour </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" id="min_17" name="q17_departure17[min]" type="text" size="2" maxlength="2" value="29" />
            <label class="form-sub-label" for="min_17" id="sublabel_minutes"> Minutes </label></span><span class="form-sub-label-container"><select class="form-dropdown validate[required]" id="ampm_17" name="q17_departure17[ampm]">
              <option value="AM"> AM </option>
              <option value="PM"> PM </option>
            </select>
            <label class="form-sub-label" for="ampm_17"> &nbsp;&nbsp;&nbsp; </label></span><span class="form-sub-label-container"><img alt="Pick a Date" id="input_17_pick" src="http://jotform.me/images/calendar.png" align="absmiddle" />
            <label class="form-sub-label" for="input_17_pick"> &nbsp;&nbsp;&nbsp; </label></span>
        </div>
      </li>
      <li class="form-line" id="id_9">
        <label class="form-label-left" id="label_9" for="input_9">
          E-mail<span class="form-required">*</span>
        </label>
        <div id="cid_9" class="form-input">
          <input type="email" class="form-textbox validate[required, Email]" id="input_9" name="q9_email9" size="30" />
        </div>
      </li>
      <li class="form-line" id="id_20">
        <label class="form-label-left" id="label_20" for="input_20">
          Choose Your Room<span class="form-required">*</span>
        </label>
        <div id="cid_20" class="form-input"><span class="form-product-item"><input class="form-radio validate[required]" type="radio" id="input_20_1002" name="q20_chooseYour[][id]" value="1002" />
            <label for="input_20_1002">
              Super Suite Room<span class="form-product-details"><b>
                  $<span id="">450.00</span>
                  USD
                </b></span>
            </label></span>
          <br /><span class="form-product-item"><input class="form-radio validate[required]" type="radio" id="input_20_1003" name="q20_chooseYour[][id]" value="1003" />
            <label for="input_20_1003">
              Deluxe Continental Room<span class="form-product-details"><b>
                  $<span id="">550.00</span>
                  USD
                </b></span>
            </label></span>
          <br /><span class="form-product-item"><input class="form-radio validate[required]" type="radio" id="input_20_1004" name="q20_chooseYour[][id]" value="1004" />
            <label for="input_20_1004">
              Presidential Elegant Room<span class="form-product-details"><b>
                  $<span id="">1,500.00</span>
                  USD
                </b></span>
            </label></span>
          <br />
          <br /><span class="form-payment-total"><b>
              Total:&nbsp;<span>$<span id="payment_total">0.00</span>
                USD</span></span>
          </b>
        </div>
      </li>
      <li class="form-line" id="id_16">
        <div id="cid_16" class="form-input-wide">
          <div style="margin-left:156px" class="form-buttons-wrapper">
            <button id="input_16" type="submit" class="form-submit-button">
              Submit
            </button>
          </div>
        </div>
      </li>
    </ul>
    <ul class="form-section-closed" style="height: 60px;clear:both;" id="section_21">
      <li id="cid_21" class="form-input-wide">
        <div class="form-collapse-table" id="collapse_21"><span class="form-collapse-mid" id="collapse-text_21">Thank You !!</span><span class="form-collapse-right form-collapse-right-hide">&nbsp;</span>
        </div>
      </li>
      <li class="form-line" id="id_23">
        <label class="form-label-left" id="label_23" for="input_23"> Number </label>
        <div id="cid_23" class="form-input">
          <input type="number" class="form-textbox validate[Numeric]" id="input_23" name="q23_number23" size="5" />
        </div>
      </li>
      <li style="display:none">
        Should be Empty:
        <input type="text" name="website" value="" />
      </li>
    </ul>
  </div>

  <input type="hidden" id="simple_spc" name="simple_spc" value="21987757374471" />
  <script type="text/javascript">
  document.getElementById("si" + "mple" + "_spc").value = "21987757374471-21987757374471";
  </script>
  <input type="hidden" class="form-hidden" value="4132432" id="input_22" name="q22_bookingNumber" />
</form>